317:35-15-10. Medical eligibility redetermination for State Plan Personal Care (SPPC) services
(a) Medical eligibility redetermination. The Oklahoma Human Services (OKDHS) Health Care Management Nurse (HCMN) III completes a medical redetermination before the end of the long-term care medical certification period.
(b) Recertification. The OKDHS HCMN I or II re-assesses the SPPC service members eighteen (18) years of age and older, for medical re-certification based on the member's needs and level of caregiver support required, using the Uniform Comprehensive Assessment Tool (UCAT) at least every thirty-six (36) months. Members younger than eighteen (18) years of age, are re-evaluated by the OKDHS HCMN I or II using the UCAT on a twelve (12) month basis or sooner when needed. During this re-certification assessment, the OKDHS HCMN I or II informs the member of the state's other SoonerCare (Medicaid) long-term care options. The OKDHS HCMN I or II submits the re-assessment to the OKDHS HCMN III for recertification. Documentation is sent to the OKDHS area nurse no later than the tenth (10th) calendar day of the month certification expires. When the OKDHS HCMN III determines medical eligibility for SPPC services, a recertification review date is entered on the system.
(c) Change in amount of units or tasks. When the SPPC provider agency determines a need for a change in the amount of units or tasks in the service, a care plan is completed and submitted to OKDHS within five (5) business days of identifying the assessed need. The OKDHS HCMN III approves or denies the change prior to implementation.
(d) SPPC services voluntary closure. When a SPPC member decides personal care services are no longer needed to meet his or her needs, a medical decision is not needed. The member is sent a Voluntary Withdrawal Request for confirmation and signature, and the request is entered into the electronic system upon receipt. A closure notification is submitted to the provider agency via the electronic system.
(e) Resuming personal care services. When a SPPC member approved for SPPC services is without services for less than ninety (90) calendar days, but the member has current medical and SoonerCare (Medicaid) financial eligibility approval, SPPC services may be resumed using the member's previously approved plan. The personal care provider agency nurse contacts the member to determine when changes in health or service needs occurred. When changes are identified, the provider agency nurse completes an assessment visit and submits a SPPC services skilled nursing need re-assessment within ten (10) business days of the resumed plan start date. When the member's needs dictate, the personal care provider agency may submit a request for a change in authorized SPPC service units. When no changes occur, the agency nurse documents the contact in the electronic system for the OKDHS HCMN I or II ten (10) business days of the resumed plan start date.
(f) Financial ineligibility. When the OKDHS social services specialist (SSS) determines a member does not meet SoonerCare (Medicaid) financial eligibility criteria, the OKDHS HCMN III is notified to initiate the closure process due to financial ineligibility. When OKDHS determines a member to be financially ineligible for SPPC services, they notify the member of the determination, and his or her right to appeal the decision in writing. A closure notification is submitted to the provider agency.
(g) Closure due to medical ineligibility. When OKDHS determines to be medically ineligible for SPPC services, they notify the member of the determination, and his or her right to appeal the decision, in writing. When medical eligibility redetermination is not made prior to current medical eligibility expiration, the existing medical eligibility certification is automatically extended until care level redetermination is established. For members:
(1) Who are not hospitalized or in an extended medical care facility, the existing medical eligibility certification is extended for a maximum sixty (60) calendar days from the date of the previous medical eligibility expiration date;
(2) Who are hospitalized or in an extended medical care facility, the existing medical eligibility certification is extended for thirty (30) calendar days from the date of discharge from the facility or for sixty (60) calendar days from the date of previous medical eligibility expiration date, whichever is longer;
(3) Whose medical eligibility redetermination is not made by applicable extended deadline, the member is determined to be medically ineligible; or
(4) Who no longer meet medical eligibility or cannot be located to complete the redetermination assessment, the HCMN I or II notifies the HCMN III. The HCMN III updates the system's medical eligibility end date and notifies the HCMN I or II of effective end date. A closure notification is submitted to the provider agency.
(h) State Plan Personal Care services termination.
(1) State Plan Personal Care (SPPC) services may be discontinued when:
(A) Professional documentation supports the member poses a threat to self or others;
(B) Other household members or persons who routinely visit the household who, as professional or credible documentation supports, pose a threat to the member or other household visitors;
(C) The member or the other household members use threatening, intimidating, degrading, or sexually inappropriate language or innuendo or behavior towards service providers, either in the home or through other contact or communications. Efforts to correct such behavior are unsuccessful as professional or credible documentation supports;
(D) The member or family member fails to cooperate with SPPC service delivery or to comply with Oklahoma Health Care Authority (OHCA) or OKDHS rules as professional or credible documentation supports;
(E) The member's health or safety is at risk as professional or credible documentation supports;
(F) Additional services, either "formal" such as, paid by Sooner Care (Medicaid) or some other funding source or "informal" such as, unpaid are provided in the home. This eliminates the need for SoonerCare SPPC services;
(G) The member's living environment poses a physical threat to self or others as professional or credible documentation supports, and measures to correct hazardous conditions or assist the person to move are unsuccessful or are not feasible; or
(H) The member refuses to select or accept a provider agency or Personal Care Assistant (PCA) service for ninety (90) consecutive days as professional or credible documentation supports.
(2) For members receiving SPPC services, the provider agency submits documentation with the recommendation to discontinue services to OKDHS. The OKDHS HCMN I or II reviews the documentation and submits it to the OKDHS HCMN III for determination. The personal care provider agency or PCA and the local OKDHS social services specialist is notified of the decision to terminate services via the electronic system. The member is sent an official closure notice informing him or her of appropriate member rights to appeal the decision to discontinue services.